The wide-ranging rule represented the most major change to standards for critical-access hospitals since 1997. It included a requirement that hospitals must have infection prevention and antibiotic stewardship programs for healthcare-related infections and for the proper use of antibiotics. In addition, the CMS proposed that hospitals adopt nondiscrimination policies that expand protections based on gender identity and sexual orientation. The rule also had several provisions meant to hasten patients' access to their healthcare records.

In all, the CMS estimated that implementing the rule would cost the industry $773 million to $1.1 billion.

The rule won wide industry support when it was proposed, although there were some concerns about several of the provisions outlined in public comments.

The Catholic Health Association pushed back against the new anti-discrimination language related to gender identity over concerns that it would conflict with moral or religious objections to providing medical or surgical gender-transition services.

It requested HHS include a religious exemption from the proposed requirements.

Adventist Health System expressed concern about the new anti-infection proposals, as the system questioned whether they would have much impact when healthcare settings outside hospitals aren't required to make similar efforts.

Many antibiotic-resistant organisms come into the hospital from these other settings, according to Adventist. The health system recommended that the CMS clarify the new standard to reflect that there are some circumstances that are beyond the hospitals' control.

Allina Health, a system of 13 hospitals, raised concerns about the rule proposing that patients may access their records via an oral or written request. It wanted the phrase "oral" omitted from the final version of the rule because requests in writing better allow providers time to confirm a patient's identity before documents are released.

Allina also said it was concerned about regulatory burden around a proposal that a request for medical records be completed within 30 days for inpatient stays and within seven days for outpatient visits.

Such an approach would pose an administrative burden; Allina recommended that the CMS adopt one consistent 30-day time frame regardless of the patient's status.

It is unclear whether the CMS will adopt any of the industry's recommendations. The agency hopes to have the final version of the rule out by June 2019.